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Saturday, 8 December 2012

Limits to medicalization?

The character Syndrome from The Incredibles pictured a world where everybody had super powers: “because when everyone is super, no one will
be”. If more than 50% of the population have depression, then what is ‘normal’?
What if it was 75% of the population? Are we witnessing a gradual approach to a
situation where we will reach the Last Well
Person? Is a well person simply a patient
who has not been completely worked up?
There is a difference between being upset, sad, grieved, annoyed
with work, tired or having backache, headache, listlessness, low libido,
dizziness, altered bowel motions, baldness, worn out joints, disturbed sleep, and
anxiety on the one hand, and being diseased on the other. The latter comes
under the medical domain and demands labelling, documentation of disability,
and above all, treatment.

In 1975, Ivan Illich wrote “Limits to Medicine”, a stinging
attack on medicine, highlighting the medicalization of ‘life’, and iatrogenesis
(medical harm), and questioning whether the balance of benefit and harm from
medicine was a positive one. Since then, medicalization has gone ahead in leaps
and bounds, forming an insatiable medical-industrial monster that is consuming
larger and larger portions of government and personal money, time and parts of
our lives previously thought to be just that: part of life. But is there a
limit to medicalization? This article explores medicalization, in a ‘1-to-100’
format. Feel free to bookmark it and come back later to browse. I intend
updating it when new examples arise.

14% increase in new
medical graduates in Australia in 2012, and yet they are still claiming a
doctor shortage. More doctors mean more medicalization;
medicine is unique in that supply drives demand (here, here,
and anything from Dartmouth).

36%
of referrals for cardiac stents from patients with heart attacks were found to
be ‘false positives’, subjecting them to increased risks. The medicalization of
heart disease is total, and the intervention
rate is too high.

37% of men in the world
have raised cholesterol(only another
14% and it would be normal).

42% of patients with
Fibromyalgia also have Chronic Fatigue Syndrome, 39% have Irritable Bowel Syndrome, and 45% have
migraine. There are no tests or biological markers for any of these ‘diagnoses’
(read: labels).

44% of findings from major medical journals (usually
indicating that the treatment studied is effective) are replicated by later
studies. The rest are either refuted by later studies or go unchallenged. This
shows that our initial impression of new treatments is an overestimate, yet it
dictates treatment for years to come. Eventual reversal of
medical practice is common.

45% of elderly patients presenting to emergency departments
are on 5 or more medications, 20 – 40% of which are unnecessary.

47% of all non-traumatic
deaths in people over the age of 65 in the USA (in 2001) occurred in hospital(many of them receiving active, non-palliative treatment
right up until death).

48% cesarean section rate in the private sector in Peru
after introduction of “health reforms”, up from 27% 10 years earlier; compared
to 19% rate in the public sector, which did not increase over that period.

49%
of patient requests for interventions secondary to viewing direct-to-consumer
advertising (DTCA) are considered in appropriate. Unfortunately this doesn’t stop
physicians from prescribing anyway. DTCA creates demand for medical
interventions; it medicalizes.

50%
of heart attacks occur in people with normal or low cholesterol levels. The
‘cholesterol hypothesis’ has
been questioned.

58%
increase in CT scans in Canada between 2003 and 2009, along with a 100% increase
in MRIs, despite 30% of CT scans being inappropriate and contributing no useful
information. In the US alone, it is estimated that $30
billion per year is wasted on CT and MRI scans.

59% of people ‘living with dementia’ remain undiagnosed. Why
do we feel the need to diagnose (label) them?

60% lifetime risk of
psychiatric disorder in New Zealand(and this number is not unique to New Zealand).

64% of men in their 70’s have prostate cancers (found on
autopsy, nearly all incidental) yet screening only detects 5-10% - these are
the ones that get taken out, for little or no benefit to overall survival.

65% of all deaths in US now occur in hospital, increasing the
risk of ‘futile’ end-of-life care: medicalizing dying.

66% of admissions for adverse drug reactions in the elderly
are due to unintentional overdose. There are about 100,000 admissions per year
in the US due to adverse drug reactions in the elderly. The problem is
magnified by “polypharmacy” whereby up to 40% of elderly patients are taking unnecessary
medications, and about half of the elderly take 5 or more medications.

67% of mammography detected breast tumours are low risk, yet
these questionable ‘tumours’ get treated the same as invasive cancers. This
overdiagnosis (500-fold increase in diagnosis of ‘cancer-in-situ’) has led to
the increase in breast cancer incidence and to the current state of
overtreatment and its attendant harms. Like with prostate cancer: more people are
diagnosed with ‘cancer’ each year, but the same number of people are dying of
breast cancer each year, therefore the proportion
of people with ‘cancer’ who die of cancer each year goes down, without saving
any lives.

68% reduction in cases of whiplash after legislative change
in Australia. Geographic variations in whiplash are stark (in some areas it
does not exist), and the disease has all the hallmarks of a “culturally constructed illness behaviour”. This is supported by the lack of any reliable physical /
investigation findings.

69%: the upper limit of the inflation in reported
effectiveness between published studies of antidepressants and the reality. The
fact that these drugs are largely ineffective
except in major depression indicates that we are medicalizing
sadness.

73% of Americans would
rather have a full body CT scan (a complete waste of time, and possibly
harmful) than be given $1,000.

74% increase in US
tonsillectomy rate in decade to 2006(despite a lack of evidence of effectiveness in most
cases).

75%
of men over 50 in the US have had prostate cancer screening using a PSA test,
leading to false positives and overdiagnosis and overtreatment of a condition
that is often non-fatal, and using a test (PSA) that is not
recommended and does not result in a reduction in all-cause mortality.

76% of individuals 20-79
have an “unfavourable cardiovascular risk profile”.

77% of seniors have two or
more chronic diseases.Or are they
just old?

78% of healthy people aged 70-79 (without COPD - Chronic
Obstructive Pulmonary Disease) would be diagnosed with COPD according to
proposed diagnostic criteria from the Global Initiative for Chronic Obstructive
Lung Disease.

90%: the proportion of
Americans would be on (cholesterol lowering) statins (if the drug companies had their
way).

91% increase in death from poisoning amongst US
teenagers from 2000 to 2009, primarily due to abuse of prescription drugs.

92%
of patients with colds (viral) are prescribed antibiotics (that are not
effective).

93% of children avoiding
certain foods based on allergy tests were found to have no reaction to oral
testing of those foods.

94%
of women surveyed thought that women with breast cancers detected by mammography benefited
from that diagnosis. The question of overdiagnosis and treatment, and the
balance between risk and harm from mammography is not
that clear.

95%
of people exposed to a traumatic event experience some mental distress. 99%
exposed to war satisfy the criteria for PTSD. Isn’t some degree of distress
after such events normal? Does labelling and treatment help?

96% of breast cancer patients considering chemotherapy rate
“living as long as possible” as their No 1 priority, according to doctors.
According the patients themselves, it is only 53%. This explains why chemo is
universally recommended by doctors, as quality of life is not adequately taken
into consideration.

97% of people with celiac
disease don’t even know they have it (so does that make it a problem or
not?)

I think you can manipulate statistics anyway you want to. For instance...93% of children avoiding certain foods based on allergy tests were found to have no reaction to oral testing of those foods. Since food allergy testing can be IgG or IgE, this statistic makes no sense. IgG reactions are delayed reactions within the blood and can happen up to 72 hours after ingestion of the particular allergen. If all food allergy tests were based solely on IgE reactions looking for anaphylaxis then I can see how this particular statistic might make sense.

You can certainly manipulate data to make your case seem stronger. That is at least partly my point. When we have ridiculously high rates of (say) depression or ADHD, you have to ask about the definitions being used.

Re 81% prevalence of Osteoporosis. Surprised you didn't pick up on the osteoporosis diagnostic criteria - 2SD below the bone density of a 25yr old. Of course all the elderly have the 'disease', it's good for marketing. And as for the drugs, well....

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About this blog

This blog explores the true effectiveness of medical interventions, established through scientific study, as opposed to the perceived effectiveness. This highlights our overestimation of the benefits and underestimation of the harms from these interventions.

About Me

Why be skeptical about medicine?

Doctors and skeptics are often critical of alternative medicine and other non-medical healing practices because they are not well supported by scientific evidence. This is appropriate.What is inappropriate is the acceptance of medical practices (established and new) without a requirement for the same level of scientific support.The evidence supporting many medical practices is less than many people suppose, and similarly, the harms from medicine are often under-appreciated.We need to ask the same question of medicine that we would ask the alternative practitioner: what is the evidence? But we need skills to be able to critically appraise that evidence, because unlike (say) homeopathy, medical evidence is based on science. This is part of the problem because for many, being scientifically based is reason enough for a treatment to be accepted as true; assuming that a medical treatment works is our default position. This, and the other biases that creep into medical science on so many levels, at least partly due to our keenness to see it work, are the reasons for looking at medicine with a skeptical eye.